Pathophysiology, prevention, and treatment of ebullism.

INTRODUCTION: Ebullism is the spontaneous evolution of liquid water in tissues to water vapor at body temperature when the ambient pressure is 47 mmHg or less. While injuries secondary to ebullism are generally considered fatal, some reports have described recovery after exposure to near vacuum for several minutes. The objectives of this article are to review the current literature on ebullism and to present prevention and treatment recommendations that can be used to enhance the safety of high altitude activities and space operations. METHODS: A systematic review was conducted on currently available information and published literature of human and animal studies involving rapid decompression to vacuum and ebullism, with subsequent development of an applicable treatment protocol. RESULTS: Available research on ebullism in human and animal subjects is extremely limited. Literature available identified key pathophysiologic processes and mitigation strategies that were used for treatment protocol design and outlining appropriate interventions using current best medical practices and technologies. DISCUSSION: Available literature suggests that the pathophysiology of ebullism leads to predictable and often treatable injuries, and that many exposures may be survivable. With the growing number of high altitude and space-related activities, more individuals will be at risk for ebullism. An integrated medical protocol can provide guidance for the prevention and treatment of ebullism and help to mitigate this risk in the future.

Altitude decompression sickness incidence among U-2 pilots: 1994-2010.

INTRODUCTION: The U-2 aircraft exposes its pilots to cabin pressures equivalent to 29,500 ft (8992 m) during flight, placing them at risk for decompression sickness (DCS). Historical data documenting DCS in the U-2 pilot community is lacking. This study assesses how rates and types of DCS have changed temporally in the U-2 flight program. METHODS: We created a database of all DCS cases among U-2 pilots from 1994 through 2010. Cases were analyzed by date of occurrence and symptoms experienced. Flight data were collected to calculate DCS incidence rates. RESULTS: From 1994-2010, there were 73 documented DCS cases in U-2 pilots. Between 1994 and 2005, the number of annual cases ranged from 0-5; between 2006 and 2010, the number of annual cases increased to 6-10. Additionally, there was a trend toward more severe (neurologic and pulmonary) cases between 2006 and 2010 with 22 cases compared to 10 cases the preceding 12 yr. The most common presentations of U-2 DCS were joint pain (59%), mainly involving large joints, and generalized neurologic symptoms (44%). From 2006-2010, there was an increase in the average annual flight hours per pilot to meet wartime operational needs that correlated temporally with the increase in number and severity of DCS cases. The DCS risk per flight was 0.076% from 1994-2005 but increased to 0.23% from 2006-2010. CONCLUSIONS: DCS remains prevalent among U-2 pilots. An increase in number and severity of cases correlated temporally with increased operational tempo of the U-2 squadron. Changes in cockpit pressurization and limiting the length and frequency of hypobaric exposure may reduce future incidence.

Fifty years of decompression sickness research at Brooks AFB, TX: 1960-2010.

INTRODUCTION, FACILITIES, AND METHODS: Decompression sickness (DCS) occurring in hypobaric environments related to aviation or spaceflight was a major focus of research at Brooks AFB/City-Base, TX, throughout the period 1960-2010. Multiple hypobaric chambers and extensive support facilities were built for research on altitude DCS using both human subjects and animal models. Areas of study included symptomatology, incidence, prediction, and prevention of DCS. High-altitude aviation, spacecraft atmospheres, and pressure suits were evaluated with various decompression and prebreathing schedules to reduce DCS risk. FACTORS AFFECTING DCS INCIDENCE: The results from these efforts were recorded in an extensive Altitude DCS Research Database which served as a resource for developing reports and exploring relationships of various parameters such as altitude, time at altitude, prebreathe time, and mode of activity while decompressed. PREVENTION AND PREDICTION OF DCS: Individual susceptibility to DCS was also evaluated in an effort to tailor preventive measures and predict susceptibility. Completion of the 26 human-use protocols provided information which was incorporated into NASA and USAF operational practices to reduce DCS risk. DOCUMENTATION: DCS researchers working at Brooks throughout this period produced 177 papers documenting results of thousands of subject-exposures and other experiments. An Altitude DCS Risk Assessment Computer Model was fielded in 2005. This review centers on the results of research at Brooks and notes questions about operational DCS risk that have not yet been answered.

Neurological altitude decompression sickness among U-2 pilots: 2002-2009.

INTRODUCTION: Compared to the previous 47 yr, U-2 pilots reported an increased number of altitude decompression sickness (DCS) incidents with central nervous system (CNS) manifestations during 2002-2009. Due to increasing incident severity during military operations, the U.S. Air Force initiated an investigation to prevent future mishaps. METHODS: We retrospectively examined all neurological DCS cases observed among U-2 pilots during 2002-2009. Urgency to prevent further pilot losses limited this study to using existing, often incomplete data sources. RESULTS: During 2002-2009, 16 confirmed incidents of CNS DCS occurred with 13 pilots, plus 4 possible incidents with 4 pilots. Significantly, 12 of 16 confirmed incidents occurred at 1 operating location, including 4 of 5 life-threatening cases. This series of cases were of a type and severity rarely found in flight operations and correlated temporally with increased sortie frequency/duration associated with combat operations. Multiple investigations confirmed no defects in aircraft, support equipment, or oxygen supplies. Nor were significant trends observed with age, habitus, environmental exposure, medication use, or cardiac defects. In 11 cases, symptom recognition occurred well after the 4-h point where clinical experience indicated risk should stabilize. Symptoms also recurred days later and responded to repeat hyperbaric oxygen therapy in three of four cases. Finally, neuropsychiatric symptoms persisted in six pilots for years and may represent permanent injury. CONCLUSIONS: An increase in U-2 CNS DCS cases probably resulted from more cockpit activity combined with longer, more frequent high-altitude exposures. Adjustments in preoxygenation, cabin altitude, exercise at altitude, and frequency of flights may reduce incidence.

Air break during preoxygenation and risk of altitude decompression sickness.

INTRODUCTION: To reduce the risk of decompression sickness (DCS), current USAF U-2 operations require a 1-h preoxygenation (PreOx). An interruption of oxygen breathing with air breathing currently requires significant extension of the PreOx time. The purpose of this study was to evaluate the relationship between air breaks during PreOx and subsequent DCS and venous gas emboli (VGE) incidence, and to determine safe air break limits for operational activities. METHODS: Volunteers performed 30 min of PreOx, followed by either a 10-min, 20-min, or 60-min air break, then completed another 30 min of PreOx, and began a 4-h altitude chamber exposure to 9144 m (30,000 ft). Subjects were monitored for VGE using echocardiography. Altitude exposure was terminated if DCS symptoms developed. Control data (uninterrupted 60-min PreOx) to compare against air break data were taken from the AFRL DCS database. RESULTS: At 1 h of altitude exposure, DCS rates were significantly higher in all three break in prebreathe (BiP) profiles compared to control (40%, 45%, and 47% vs. 24%). At 2 h, the 20-min and 60-min BiP DCS rates remained higher than control (70% and 69% vs. 52%), but no differences were found at 4 h. No differences in VGE rates were found between the BiP profiles and control. DISCUSSION: Increased DCS risk in the BiP profiles is likely due to tissue renitrogenation during air breaks not totally compensated for by the remaining PreOx following the air breaks. Air breaks of 10 min or more occurring in the middle of 1 h of PreOx may significantly increase DCS risk during the first 2 h of exposure to 9144 m when compared to uninterrupted PreOx exposures.

Cognition Effects of Low-Grade Hypoxia.

INTRODUCTION: The effects of low-grade hypoxia on cognitive function are reported in this paper. The study compared cognitive function during short exposures at four different altitudes. METHODS: Ninety-one subjects were exposed to simulated altitudes of ground level, 1524, 2438, and 3658 m (5000, 8000, and 12,000 ft) in the Brooks City-Base altitude pressure chamber in a balanced design. Oxygen saturation, heart rate, and cognitive performance on seven different cognitive tasks were measured. In addition, subjects indicated their symptoms from a 33-item subjective symptom survey. RESULTS: As designed, oxygen saturation decreased and heart rate increased with higher altitudes. Very small degradations in performance were found at the two highest altitudes for only two of the cognitive tasks (continuous performance and grammatical reasoning). In the subjective symptom survey, 18 of the 33 possible symptoms were more common at 3658 m (12,000 ft) than at ground level. CONCLUSIONS: The findings indicated a minimal influence of low-grade hypoxia on cognitive performance in contrast to some existing classic symptoms of hypoxia. Pilmanis AA, Balldin UI, Fischer JR. Cognition effects of low-grade hypoxia. Aerosp Med Hum Perform. 2016; 87(7):596-603.

Altitude decompression sickness between 6858 and 9144 m following a 1-h prebreathe.

INTRODUCTION: The zero prebreathe altitude threshold for developing 5% decompression sickness (DCS) symptoms in men has been reported to be 6248 m (20,500 ft). However, such an altitude threshold when 1 h of oxygen prebreathe is used has not been well documented and was the primary purpose of this study. METHODS: The 51 male human subjects were exposed to 9144 m (30,000 ft), 8382 m (27,500 ft), 7620 m (25,000 ft), and/or 6858 m (22,500 ft) for 8 h. They were monitored for symptoms of DCS and venous gas emboli (VGE). RESULTS: DCS symptom incidence after 4 h of exposure decreased with exposure altitude from 87% at 9144 m to 26% at 6858 m. VGE were lower during the 4-h 6858-m exposures (32%) than at the higher altitudes (76-85%). The symptom incidences during the first 4 h of exposure were lower at 6858 m and 7620 m following a 1-h prebreathe as compared with analogous zero-prebreathe exposures. There were no differences between incidences of VGE or DCS at any of the four altitudes after 8 vs. 4 h of exposure. CONCLUSION: The altitude threshold for 5% DCS symptoms is below 6858 m after 1 h of prebreathe. However, during 6858-m and 7620-m exposures, a 1-h prebreathe is highly beneficial in reducing DCS incidence and delaying the onset of DCS, keeping the incidence to less than 6% during the first 90 min of exposure. Use of 4-h vs. 8-h exposures does not appear to underestimate DCS risk at or above 7620 m.

Headache and altitude decompression sickness: joint pain or neurological pain?

INTRODUCTION: Exposure to reduced ambient pressure may result in decompression sickness (DCS). Headache is among the DCS symptoms encountered and is usually regarded as neurological DCS, which is traditionally classified as serious DCS. Since cranial sutures may be considered joints, it is possible that some headaches are actually joint pain and when associated with decompression sickness need not be neurological DCS. METHODS: Records were individually recovered from the Davis Hyperbaric Laboratory at Brooks City-Base, TX. Information was extracted using a detailed survey instrument. Possible joint pain headache cases were identified using three criteria: headache localized at a suture, normal neurologic exam, and resolution within 30 min of hyperbaric oxygen treatment. RESULTS: A total of 729 records documenting treatment for DCS were scrutinized. Of these, 70 cases of altitude DCS with headache were examined. Analysis, using the three criteria, showed 23% (16 cases) of altitude headache DCS symptoms could potentially be re-classified as joint pain. CONCLUSION: Generally, headache DCS is considered neurological DCS. However, since cranial sutures are joints, both histologically and functionally, and since DCS most commonly affects joints, headache DCS may, at times, be joint pain DCS. Indeed, retrospective data analysis suggests that this possibility exists. Such a reclassification from neurological to joint pain DCS would lessen the aeromedical impact of a DCS headache.

Partial pressure of nitrogen in breathing mixtures and risk of altitude decompression sickness.

BACKGROUND: Many aircraft oxygen systems do not deliver 100% O2. Inert gases can be present at various levels. The purpose of this study was to determine the effect of these inert gas levels on decompression sickness (DCS). METHODS: Subjects were exposed for 4 h to 5486 m (18,000 ft) with zero prebreathe, using either mild (Test A) or strenuous exercise (Test B), and breathing 60%N2/40%O2. Test C used a breathing mixture of 40%N2/60%O2 at 6858 m (22,500 ft) with zero prebreathe and mild exercise. Test D investigated a breathing mixture of 2.8%N2/4.2%argon/93%O2 with 4 h exposures to 7620 m (25,000 ft), mild exercise, and 90 min of preoxygenation. The controls were from previous studies using similar conditions and 100% O2. RESULTS: The DCS risk for Tests A and B and the Control for B was 7%; the Control for Test A was 0% (n.s.). Breathing the 40%N2/60%O2 mixture (Test C) resulted in 43% DCS compared with 53% DCS with 100% O2 (n.s.). When the 2.8%N2/4.2%argon/93%O2 mixture was used, the results showed 25% DCS compared with 31% DCS with 100% O2 (n.s.). CONCLUSIONS: The increased nitrogen and argon levels in the breathing gas while at altitudes of 5486 m to 7620 m did not increase DCS risk. These results support the concept of using the partial pressure gradient of inert gases instead of the percentage of N2 or argon in a breathing gas mixture to determine the risk of DCS during altitude exposure.

Depressurization in military aircraft: rates, rapidity, and health effects for 1055 incidents.

INTRODUCTION: Aircraft cabin depressurization is a rare event but one which demands attention because of the grave potential for aircrew incapacity in flight. The purpose of the current study was to determine rates of depressurization incidents for U.S. military aircraft, to examine their causes, and to evaluate the medical importance of these incidents. METHODS: The U.S. Navy and U.S. Air Force safety center databases were searched for decompression incidents during FY1981-FY2003. A total of 1055 incidents were analyzed as to the cause, speed of onset, and adverse health effects (hypoxia, barotrauma, DCS, or any combination of these). The causes of each incident were identified and classified by aircraft type. RESULTS: The number of incidents per airframe varied from 1 (in many airframes) to 276 in the T-38. The number of total hours flown ranged from 16,332 in the T-6 to 8,101,607 in the C-130. The number of sorties flown ranged from 8800 in the B-2 to 3,543,061 in the C-130. Of 35 common airframes, 30 showed rates between 0 and 20 incidents per million flying hours. Depressurization was "slow" in 83% of incidents. Of the 1055 incidents, only 350 (33.2%) involved adverse health effects. Hypoxia occurred in 221 incidents, DCS in 83, and barotrauma in 71. Only 4 (0.4%) resulted in a fatality. Of the 199 incidents involving hypoxia, 12 (6%) occurred below 4267 m (14,000 ft). CONCLUSION: Most reported military aircraft depressurization incidents are slow and do not affect aircrew health. Rates have decreased dramatically since the 1980s. Still, this study lends support to continuing hypobaric chamber training for military pilots.

Decompression sickness during simulated extravehicular activity: ambulation vs. non-ambulation.

BACKGROUND: Extravehicular activity (EVA) is required from the International Space Station on a regular basis. Because of the weightless environment during EVA, physical activity is performed using mostly upper-body movements since the lower body is anchored for stability. The adynamic model (restricted lower-body activity; non-ambulation) was designed to simulate this environment during earthbound studies of decompression sickness (DCS) risk. DCS symptoms during ambulatory (walking) and non-ambulatory high altitude exposure activity were compared. The objective was to determine if symptom incidences during ambulatory and non-ambulatory exposures are comparable and provide analogous estimates of risk under otherwise identical conditions. METHODS: A retrospective analysis was accomplished on DCS symptoms from 2010 ambulatory and 330 non-ambulatory exposures. RESULTS: There was no significant difference between the overall incidence of DCS or joint-pain DCS in the ambulatory (49% and 40%) vs. the non-ambulatory exposures (53% and 36%; p > 0.1). DCS involving joint pain only in the lower body was higher during ambulatory exposures (28%) than non-ambulatory exposures (18%; p < 0.01). Non-ambulatory exposures terminated more frequently with non-joint-pain DCS (17%) or upper-body-only joint pain (18%) as compared with ambulatory exposures, 9% and 11% (p < 0.01), respectively. DISCUSSION: These findings show that lower-body, weight-bearing activity shifts the incidence of joint-pain DCS from the upper body to the lower body without altering the total incidence of DCS or joint-pain DCS. CONCLUSIONS: Use of data from previous and future subject exposures involving ambulatory activity while decompressed appears to be a valid analogue of non-ambulatory activity in determining DCS risk during simulated EVA studies.

Altitude decompression sickness susceptibility: influence of anthropometric and physiologic variables.

INTRODUCTION: There is considerable variability in individual susceptibility to altitude decompression sickness (DCS). The Air Force Research Laboratory Altitude DCS Research Database consists of extensive information on 2980 altitude exposures conducted with consistent procedures and endpoint criteria. We used this database to quantify the variation in susceptibility and determine if anthropometric and/or physiologic variables could be used to predict DCS risk. METHODS: There were 240 subjects who participated in at least 4 of 70 exposure profiles in which between 5 and 95% of all subjects tested developed DCS symptoms. A subject/study ratio (SSR) was calculated by dividing the DCS experienced by a subject during all their exposures by the DCS incidence for all subjects who participated in the identical exposures. The SSR was used to identify the relative susceptibility of subjects for use in analyzing possible relationships between DCS susceptibility and the variables of height, weight, body mass index, age, percent body fat, and aerobic capacity. RESULTS: The DCS incidence was 46.5% during 1879 subject-exposures by subjects exposed at least 4 times. A significant relationship existed between higher DCS susceptibility and the combination of lower aerobic capacity and greater weight (p < 0.05). DISCUSSION: Despite a correlation, less than 13% of the variation in DCS susceptibility was accounted for by the best combination of variables, weight and VO2max. CONCLUSION: Differences in DCS susceptibility cover a wide range and appear to be related to some anthropometric and physiologic variables. However, there was insufficient correlation to allow prediction of an individual's susceptibility.

Decompression sickness latency as a function of altitude to 25,000 feet.

INTRODUCTION: Current Air Force Instructions (AFIs) allow flight of unrestricted duration in unpressurized aircraft up to 25,000 ft. Supplemental oxygen is required to prevent hypoxia, but decompression sickness (DCS) is not adequately considered in current oxygen use guidelines. Recent information from the Air Force Research Laboratory (AFRL) DCS database, combined with a projected increase in exposure to these altitudes under proposed USAF missions, suggests that DCS may be operationally significant in certain circumstances. METHODS: The AFRL Altitude Decompression Sickness Risk Assessment Computer (ADRAC) model was used to develop a family of curves representing DCS latency (time to symptom onset) as a function of altitude for the case of zero preoxygenation and mild exercise. The DCS database was then searched for serious DCS cases among subjects under the same conditions (n = 175). An upper limit for DCS incidence that avoided serious DCS symptoms was selected and exposure time limits were determined. Preoxygenation requirements necessary to remain below the selected DCS incidence limit were also evaluated using ADRAC and provide an alternative to time limits. RESULTS AND DISCUSSION: The 20% DCS curve met the above criteria. Based on this, continued unlimited exposure time is recommended for 21,000 ft and below. The 20% DCS risk curve for zero-prebreathe exposures to 25,000 ft, 24,000 ft, 23,000 ft, and 22,000 ft are reached at 45 min, 70 min, 120 min, and 200 min, respectively. Consistent with existing AFIs, flying unpressurized above 25,000 ft is not recommended. These times should be reduced for crewmembers engaged in heavy physical activity at altitude. CONCLUSIONS: This article proposes time limits for unpressurized flight above 21,000 ft to reduce DCS risk.

Gender not a factor for altitude decompression sickness risk.

INTRODUCTION: Early, retrospective reports of the incidence of altitude decompression sickness (DCS) during altitude chamber training exposures indicated that women were more susceptible than men. We hypothesized that a controlled, prospective study would show no significant difference. METHODS: We conducted 25 altitude chamber decompression exposure profiles. A total of 291 human subjects, 197 men and 94 women, underwent 961 exposures to simulated altitude for up to 8 h, using zero to 4 h of preoxygenation. Throughout the exposures, subjects breathed 100% oxygen, rested or performed mild or strenuous exercise, and were monitored for precordial venous gas emboli (VGE) and DCS symptoms. RESULTS: No significant differences in DCS incidence were observed between men (49.5%) and women (45.3%). However, VGE occurred at significantly higher rates among men than women under the same exposure conditions, 69.3% and 55.0% respectively. Women using hormonal contraception showed significantly greater susceptibility to DCS than those not using hormonal contraception during the latter two weeks of the menstrual cycle. Significantly higher DCS incidence was observed in the heaviest men, in women with the highest body fat, and in subjects with the highest body mass indices and lowest levels of fitness. CONCLUSION: No differences in altitude DCS incidence were observed between the sexes under our test conditions, although men developed VGE more often than women. Age and height showed no significant influence on DCS incidence, but persons of either sex with higher body mass index and lower physical fitness developed DCS more frequently.

Central nervous system decompression sickness and venous gas emboli in hypobaric conditions.

INTRODUCTION: Altitude decompression sickness (DCS) that involves the central nervous system (CNS) is a rare but potentially serious condition. Identification of early symptoms and signs of this condition might improve treatment. METHODS: We studied data from 26 protocols carried out in our laboratory over the period 1983-2003; all were designed to provoke DCS in a substantial proportion of subjects. The data set included 2843 cases. We classified subject-exposures that resulted in DCS as: 1) neurological DCS of peripheral and/or central origin (NEURO); 2) a subset of those that involved only the CNS (CNS); and 3) all other cases, i.e., DCS cases that did not have a neurological component (OTHER). For each case, echo imaging data were used to document whether venous gas emboli (VGE) were present, and their level was classified as: 1) any level, i.e., Grade 1 or higher (VGE-1); and 2) high level, Grade 4 (VGE-4). RESULTS: There were 1108 cases of altitude DCS in the database; 218 were classified as NEURO and 49 of those as CNS. VGE-1 were recorded in 83.8% of OTHER compared with 58.7% of NEURO and 55.1% of CNS (both p < 0.001 compared with OTHER). The corresponding values for VGE-4 were 48.8%, 37.0%, and 34.7% (p < 0.001, compared to OTHER). Hyperbaric oxygen (HBO) was used to treat about half of the CNS cases, while all other cases were treated with 2 h breathing 100% oxygen at ground level. DISCUSSION: Since only about half of the rare cases of hypobaric CNS DCS cases were accompanied by any level of VGE, echo imaging for bubbles may have limited application for use as a predictor of such cases.

Altitude decompression sickness at 7620 m following prebreathe enhanced with exercise periods.

INTRODUCTION: Over 80% altitude decompression sickness (DCS) was reported during a 4-h exposure with mild exercise to 7620 m (25,000 ft) without prebreathe. Prebreathe for more than 1 h would be necessary to reduce the DCS risk below 40%. Use of a single period of exercise to enhance prebreathe effectiveness has been successfully tested and used during some U-2 operations. The current tests used multiple exercise sessions to enhance prebreathe (MEEP) as a means of improving denitrogenation efficiency. METHODS: Two MEEP profiles, 30 or 60 min, preceded 4-h exposures to 7620 m with mild, upper-body exercise while breathing 100% oxygen. Resting prebreathe controls were from published studies at the same laboratory. Both MEEP profiles involved 10 min of strenuous dual-cycle ergometry (75% of maximal oxygen uptake) at the beginning of prebreathe. After a 15-min rest period during the 60-min prebreathe, an additional 5 min of strenuous ergometry was performed. Mild exercise was performed during 15 of the last 20 min of both prebreathe profiles. RESULTS: The 60-min MEEP resulted in 25% DCS and the 30-min MEEP 40% DCS (N.S.). The 25% incidence of DCS following the 60-min MEEP profile was significantly less than the 63% DCS following an equal-time, resting prebreathe control. Following the 30-min MEEP, DCS incidence was not greater than the incidence following a 60-min, resting prebreathe control. There was a lower incidence of venous gas emboli during the MEEP exposures than during resting control exposures. CONCLUSION: Denitrogenation with multiple periods of exercise provides a shorter alternative to resting prebreathe for reducing DCS risk during exposure to 7620 m.

The effect of repeated altitude exposures on the incidence of decompression sickness.

INTRODUCTION: Repeated altitude exposures in a single day occur during special operations parachute training, hypobaric chamber training, unpressurized flight, and extravehicular space activity. Inconsistent and contradictory information exists regarding the risk of decompression sickness (DCS) during such hypobaric exposures. HYPOTHESIS: We hypothesized that four short exposures to altitude with and without ground intervals would result in a lower incidence of DCS than a single exposure of equal duration. METHODS: The 32 subjects were exposed to 3 different hypobaric exposures--condition A: 2 h continuous exposure (control); condition B: four 30-min exposures with descent/ascent but no ground interval between the exposures; condition C: four 30-min exposures with descent/ascent and 60 min of ground interval breathing air between exposures. All exposures were to 25,000 ft with 100% oxygen breathing. Subjects were observed for symptoms of DCS, and precordial monitoring of venous gas emboli (VGE) was accomplished with a SONOS 1000 echo-imaging system. RESULTS: DCS occurred in 19 subjects during A (mean onset 70+/-29 min), 7 subjects in B (60+/-34 min), and 2 subjects in C (40+/-18 min). There was a significant difference in DCS incidence between B and A (p = 0.0015) and C and A (p = 0.0002), but no significant difference between B and C. There were 28 cases of VGE in A (mean onset 30+/-23 min), 21 in B (41+/-35 min), and 21 in C (41+/-32 min) with a significant onset curve difference between B and A and between C and A, but not between B and C. Exposure A resulted in four cases of serious respiratory/neurological symptoms, while B had one and C had none. All symptoms resolved during recompression to ground level. CONCLUSION: Data indicate that repeated simulated altitude exposures to 25,000 ft significantly reduce DCS and VGE incidence compared with a single continuous altitude exposure.

Decompression sickness risk model: development and validation by 150 prospective hypobaric exposures.

INTRODUCTION: High altitude exposure has an inherent risk of altitude decompression sickness (DCS). A predictive DCS model was needed to reduce operational risk. To be operationally acceptable, such a theoretical model would need to be validated in the laboratory using human subjects. METHODS: The Air Force Research Laboratory (AFRL) has conducted numerous studies on human subjects exposed to simulated altitudes in hypobaric chambers. The database from those studies was used to develop a statistical altitude DCS model. In addition, a bubble growth model was developed using a finite difference method to solve for bubble radius as a function of time. The bubble growth model, integrated with the statistical model, constitutes the AFRL DCS Risk Assessment Model. Validation of the model was accomplished by comparing computer predictions of DCS risk with results from subsequent prospective human subject exposures. There were five exposure profiles, not previously found in the database, covering a wide parameter of ranges of altitude (18,000-35,000 ft), exposure time (180-360 min), prebreathe time (0-90 min), and activity level (rest-strenuous) that were used. The subjects were monitored for DCS symptoms and venous gas emboli. RESULTS: There were 30 subjects who were exposed to each of the 5 altitude profiles. The DCS incidence onset curves predicted by the model were not significantly different from the experimental values for all scenarios tested and were generally within +/- 5% of the actual values. CONCLUSION: A predictive altitude DCS model was successfully developed and validated.

The risk of altitude decompression sickness at 12,000 m and the effect of ascent rate.

INTRODUCTION: Loss of aircraft cabin pressurization can result in very rapid decompression rates. The literature contains reports of increased or unchanged levels of altitude decompression sickness (DCS) resulting from increasing the rate of decompression. We conducted two prospective exposure profiles to quantify the DCS risk at 12,192 m (40,000 ft), and to determine if there was a greater DCS hazard associated with a much higher rate of decompression than typically used during past DCS studies. METHODS: The 63 human subjects participated in 80 altitude chamber decompression exposures to a simulated altitude of 12,192 m (2.72 psia; 18.75 kPa) for 90 min, following preoxygenation with 100% oxygen for 90 min. Half of the subject-exposures involved an 8-min decompression (1,524 mpm; 5,000 fpm) and the other half experienced a 30-s decompression (mean of 24,384 mpm; 80,000 fpm). Throughout each ascent and exposure, subjects were seated at rest and breathed 100% oxygen. At altitude, they were monitored for precordial venous gas emboli (VGE) and DCS symptoms. RESULTS: The higher decompression rate yielded 55.0% DCS and 72.5% VGE and the lower rate produced 47.5% DCS and 65.0% VGE. Chi square and log rank tests based on the Kaplan-Meier analyses indicated no difference in the incidence or onset rate of DCS or VGE observed during the two profiles. CONCLUSION: Decompression rate to altitude up to 24,384 mpm was found not to have an effect on DCS risk at altitude. However, research is needed to define the DCS risk with decompression rates greater than 24,384 mpm. It was also found that the onset time to DCS symptoms decreases as altitude increases.

Moderate exercise after altitude exposure fails to induce decompression sickness.

INTRODUCTION: The objective of this study was to determine the effect of exercise after altitude exposure (post-exposure exercise) on subsequent altitude decompression sickness (DCS) incidence. Existing USAF prohibition of exercise following altitude chamber training exposures and interest from operational personnel prompted our evaluation of post-exposure exercise as a DCS-inducing stressor. METHODS: After a 1-h resting preoxygenation, 67 subjects were exposed to 30,000 ft for 2-h while performing mild, upper body exercise. The subjects were monitored for venous gas emboli (VGE) with an echo-imaging system and observed for signs and symptoms of DCS. Subjects without DCS (n = 31) or with DCS which resolved during recompression (n = 29) were randomly assigned to post-exposure rest (control, n = 29) or moderate exercise (50% of peak oxygen uptake, dual-cycle ergometry; n = 31) and both groups were monitored for delayed or recurring DCS. RESULTS: The altitude exposure resulted in 48.3% DCS in the 60 volunteers serving as test or control subjects. Of 31 subjects assigned to the post-exposure exercise group, 15 had developed DCS which resolved during descent. No cases of DCS were observed or reported during or following post-exposure exercise. CONCLUSION: The results show that moderate exercise after exposure did not result in either delayed-onset or recurring DCS.